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Shocking facts about primary health care in India, and their implications

Adam Wagstaff's picture

There’s nothing quite like a cold shower of shocking statistics to get you thinking. A paper that came out in Health Affairs today, written by my colleague Jishnu Das and his collaborators, is just such a cold shower.

Fake patients
Das and his colleagues spent 150 hours training each of 22 Indians to be credible fake patients. These actors were then sent into the consulting rooms of 305 medical providers – some in rural Madhya Pradesh (MP), others in urban Delhi – to allow the study team to assess the quality of care that the providers were delivering.

A lot of thought went into just what conditions the fake patients should pretend to have. The team wanted the conditions to be common, and to be ones that had established medical protocols with government-provided treatment checklists. The fake patients shouldn’t be subjected to invasive exams, and they needed to be able to be able to credibly describe invisible symptoms.

When the snow fell on health systems research: a symposium sketch

Adam Wagstaff's picture

Editor's warning: The author wrote this post after hitting his head and suffering some memory loss, and the World Bank cannot vouch for the accuracy of everything reported in it.

It was the perfect finale. In the vast high-tech auditorium of Beijing's International Convention Center, the audience jostled in the queue to pose questions to the final plenary panel of the Second Global Symposium on Health Systems Research

First came an elderly lady from the Indian subcontinent who asked why the panelists were so old. "How can we address the issues of tomorrow with the experts of yesterday? If we're going to be serious about universal health coverage, we need youth!" The crowd -- mostly young -- signaled their approval. A middle-aged gentleman from South Africa  tried to engage the panel on the damages inflicted on world nutrition by the global food corporations. Warming to his theme of corporate neocolonialism, land grabs, and genetically modified foods, he invoked the memory of Lenin. "That's Vladimir Lenin", he explained to the crowd, "not John Lennon." "Vladimir who? John who?" wondered the youthful crowd. The chair, the ever-youthful Lancet Editor-in-Chief Richard Horton, whose favored medium is Twitter, asked the gentleman to keep his comments tweet-length. A young woman from Britain's aid agency, DfID, eventually wrestled the mike from Lenin's apologist, and said what was on everyone's mind. "Richard, Dear Leader.", she urged, "Tell us your thoughts. It's you we want to hear!"

Health Costs and Benefits of DDT Use in Malaria Control and Prevention

Susmita Dasgupta's picture

Photo: Istockphoto.comMalaria, a life threatening mosquito-borne infectious disease, poses a risk to approximately 3.3 billion people, approximately half of the world’s population. Most malaria cases occur in Sub-Saharan Africa, but they also occur in Asia, Latin America, and to a lesser extent the Middle East and parts of Europe. In 2010, malaria was found in 106 countries and territories, with an estimated 216 million cases and nearly 0.7 million deaths – mostly among children living in Africa. In addition to its health toll, malaria places a heavy economic burden on many countries with high disease rates, with estimates of as much as a 1.3 percent reduction in GDP in those countries.

How can health systems “systematic reviews” actually become systematic?

Adam Wagstaff's picture

From Karl Pillemer’s post on Cornell’s Evidence-Based Living blogIn my post “Should you trust a medical journal?” I think I might have been a bit unfair. Not on The Lancet, which I have since discovered, via comments on David Roodman’s blog, has something of a track record of publishing sensational but not exactly evidence-based social science articles, but rather on Ernst Spaan et al. for challenging the systematicness of their systematic review of health insurance impacts in developing countries. It’s not that I now think Spaan et al. did a wonderful job. It’s just that I think they probably shouldn’t have been singled out in the way they were.

Should you trust a medical journal?

Adam Wagstaff's picture

While we non-physicians may feel a bit peeved when we hear “Trust me, I’m a doctor”, our medical friends do seem to have evidence on their side. GfK, apparently one of the world’s leading market research companies, have developed a GfK Trust Index, and yes they found that doctors are one of the most trusted professions, behind postal workers, teachers and the fire service. World Bank managers might like to know that bankers and (top) managers come close to the bottom, just above advertising professionals and politicians.

Given the trust doctors enjoy, the recent brouhaha over allegations of low quality among some of the social science articles published in medical journals must be a trifle embarrassing to the profession. Here’s the tale so far, plus a cautionary note about a recent ‘systematic review’.

Measuring universal health coverage – plus ça change?

Adam Wagstaff's picture

In case you hadn’t noticed, there’s a growing clamor for a global commitment to universal health coverage (UHC). You might have seen the recent special issue of the Lancet on “the struggle for UHC”. Inevitably, accompanying this clamor, there’s been a lot of wracking of brains on how to measure progress toward UHC. With the excitement of a new political agenda, there’s understandably a desire to carve out a new measurement agenda too. While not wanting dampen people’s enthusiasm for the UHC cause, I would like us to reflect whether on the measurement agenda we’re building enough on what’s been done before.

Feeding the poor: shifting food within and across borders

Mohini Datt's picture

While the world’s population doubled in the last fifty years, global food production trebled – especially in the staple grains that form the mainstay of the poor man’s diet.  Yet, over a billion people in the world still go hungry - why?

As the World Bank’s Global Monitoring Report of 2012 shows, it is not that the world as a whole lacks rice, wheat or maize, but produce from food abundant areas does not always make it to food deficit ones – i.e. it is not so much the availability of food that matters as access to it.
Movement of food within a country or across its borders remains hampered by dismal infrastructure and inefficient regulations, and shackled to the dictates of political economy.   Yet, trading food can feed the poor at lower costs and help countries weather shocks to local production.

Humanizing health systems

Adam Wagstaff's picture

In 1960, I wouldn’t have been writing this blog post. For a start I was just a baby at the time. Second, we were several decades away from 1994 when Justin Hall – then a student at Swarthmore – would sit down and tap out the world’s first blog. Most importantly of all, though, according to Google’s ngram viewer, people didn’t write about health systems much in 1960 (see chart). Usage of the term in books took off only in the mid 1960s, waned in the 1980s, and then started rising again in the 1990s. This doesn’t look like a statistical artifact. Usage of the term “Nobel prize” has stayed relatively constant over the period, and while the term “health economics” has also trended upwards, the growth has been much slower. So “health systems” is a fairly new term – and it’s on the rise.

Click on this image to see a larger version.

Not everyone thinks that’s a good thing.

Do Informed Citizens Receive More, or Pay More?

Philip Keefer's picture

One widely-accepted political economy research finding is that informed citizens receive greater benefits from government transfer programs. The evidence for the impact of information comes from particular contexts—disaster relief in India and welfare payments in the USA during the Great Depression.  Do other contexts yield similar results?  New research on the distribution of anti-malaria bed nets in Benin suggests:  “No.”  Instead, local health officials charged more informed households for bed nets that they could have given them for free.

The Benin context differs in three ways.  First, the policy is not the distribution of cash, but of health benefits.  Households’ access to information then influences not only their knowledge of government programs to distribute such benefits, but also the value they place on them. 

Second, the political context also differs.  In younger democracies, like Benin’s, citizens are more likely to confront additional obstacles, besides a lack of information, in their efforts to extract promised benefits from government.

Are the Knowledge Bank’s assets actually being used? The case of the World Bank’s Human Development sector

Adam Wagstaff's picture

According to its first-ever Knowledge Report, published earlier this year, the World Bank spends over $600 million a year on “core knowledge services” – research, economic and sector work, technical assistance, “knowledge management”, training, and the like. Yet as the authors of report concede, precious little is known about the impact of this spending.

In a post on this blog last year, I reported on some work that Martin Ravallion and I did on a subset of the Bank’s knowledge portfolio – formal publications. We found the publications portfolio is larger than typically thought: the Bank’s Documents and Reports (D&R) database excludes the vast majority of journal articles authored by Bank staff, and there are as many of these as there are books and other formal publications published by the Bank. We also tried to look at the impact of the Bank’s publications on development thinking, which we measured using citations in Google Scholar. We found that, despite a view by some that the Bank is more a proselytizer than a producer of new knowledge, a lot of Bank publications do get cited a lot, suggesting that these publications contain new knowledge that’s considered useful by others.

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